No. 1982 approving transfer of real property to the board of park commissioners of the park district of the COSB (SE Neighborhood Park, Fellows St. and Wenger St.)

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14 SALES DISCLOSURE FORM VState Form 46021 (R3/1 -00) Approved by State Board of Accounts, 2000 �-- Prescribed by the State Board of Tax Commissioners, 1999 Pursuant to IC 6- 1.1 -5.5 First name(s) L(s) Last name(s) City of South Bend - Department o Redevelo ment Address (number and street) Primary residence? 1200 County City Bldg. ❑Yes NO City , Town or Post Office State ZIP code South Bend IN 46601 First name(s) M.I.(s) _ r Last name(s) Address (number and street) Primary residence? 391 F- Walter Street ❑ Yes o City, Town or Post Office State ZIP code 1 " South Band IN 46614 Send tax bills and notices to this address? If no, provide mailing address (number and street, city, state, ZIP code) es ❑ No Street address Corner of Fellows Street and Wenger Street City, Town or Post Office State ZIP code South Bend IN 46601 County Township School Corporation Name St. Joseph Portage SBCSC EXEMPT TRANSACTIONS (see Instructions on reverse side) Exempt Transaction? If yes, specify the number of the exemption. (see "Exempt Transactions" on reverse side) Wes 0 #4 SALES INFORMATION 1. Total sales price $ DATE OF SALE 2. Seller paid points $ ( ) Month Day Year 3. Net sales price (line 1 minus line 2) $ 7 = Check ALL of the following conditions that apply to this sale. ❑ Transfer of entire parcel ❑ Purchase of adjoining land ❑ Vacant land O Exchange for other real property ( Trade') • Seller provided financing ❑ Mobile home ❑ Condominium ❑ Split(s) • Existence of family or business relationship between buyer and seller ❑ Personal property included in transfer (Estimated value $ ) Describe any unusual or special circumstances related to this sale, Including the specification of any less- than - complete ownership Interest, and the terms of any seller financing. ..• completed . • AUDITOR (see instructions on reverse side) County Auditor must verify and complete the following Information: • Buyer and Seller information ❑ Sales price O Parcel I Key number • Address of property transferred ❑ Conditions of sale ❑ School corporation number ❑ Date of saleltransfer ❑ Warranty deed? ❑ YES ❑ NO d by COUNTY •' (see instructions on reverse side) County Assessor must verify and complete the following Information: ASSESSED VALUE (AV) INFORMATION • Significant physical changes to property between March 1 and date of sale AV LAND $ • Current property record card attached AV IMPROVEMENT(S) $ • Property class / use code AV TOTAL $ PART 4 - Signature and Verification The parties to a real property conveyance are required to file this form and attest Section (see instructions on reverse side) in writing and under the penalties of perjury that the information contained herein is true and correct. A person who knowingly and Intentionally falsifies or omits any information required on this form commits a Class A infraction. Under penalties of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct and complete as required by law, and is prepared in accordance with IC 6- 1.1 -5.5, "Real Property Sales Disclosure Act" Sign re of Seller or re sentative Telephone number Date signed (month, day, year) Lk 4",tG rAml- dIry A,TWj%ty S74 x,35 - 9v4/ (o, a, d O3 Signature Vuyer o4dpresentative Telephone number Date signed (month, day, year)